www.nice.org.uk/guidance/TA409
▶ Aflibercept for treating choroidal neovascularisation
Aflibercept is recommended, within its marketing
authorisation, as an option for treating visual impairment
because of myopic choroidal neovascularisation in adults,
only if the manufacturer provides aflibercept with the
discount agreed in the patient access scheme.
If patients and their clinicians consider both aflibercept
and ranibizumab to be suitable treatments, the least costly
should be used, taking into account anticipated
administration costs, dosage and price per dose.
www.nice.org.uk/guidance/TA486
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (October
2016) that aflibercept (Eylea ®) is accepted for use within
BNF 78 Macular degeneration 1189
NHS Scotland in adults for the treatment of visual
impairment due to myopic choroidal neovascularisation.
This advice is contingent upon the continuing availability
of the patient access scheme in NHS Scotland or a list price
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Aflibercept 40 mg per 1 ml Eylea 2mg/50microlitres solution for
injection vials | 1 vial P £816.00
Neovascular (wet) age-related macular degeneration
(specialist use only)| Diabetic macular oedema
(specialist use only)| Macular oedema secondary to
retinal vein occlusion (specialist use only)| Choroidal
neovascularisation (specialist use only)
▶ Adult: Initially 500 micrograms once a month, to be
administered into the affected eye, until maximum
visual acuity is achieved or there are no signs of disease
activity, for continued treatment and subsequent dose
intervals—consult product literature, discontinue
treatment if no improvement in visual and anatomic
Concomitant treatment of diabetic macular oedema, or
macular oedema secondary to branch retinal vein
occlusion, with laser photocoagulation (specialist use
▶ Adult: 500 micrograms, to be administered at least
30 minutes after laser photocoagulation
ischaemic visual function loss in patients with retinal vein
l CAUTIONS Active systemic infection . diabetic macular
oedema due to type 1 diabetes (limited information
available). diabetic patients with HbA1c over 12% . history
of stroke . history of transient ischaemic attack . patients at
risk of retinal pigment epithelial tear. previous intravitreal
injections . proliferative diabetic retinopathy .retinal
detachment or macular hole (discontinue treatment if
rhegmatogenous retinal detachment or stage 3 or 4
macular holes develop). uncontrolled hypertension
CAUTIONS, FURTHER INFORMATION Ranibizumab is given
by intravitreal injection by specialists. There is a potential
risk of arterial thromboembolic events and non-ocular
haemorrhage following the intravitreal injection of
vascular endothelial growth factor inhibitors.
Endophthalmitis can occur after intravitreal injections—
patients should be advised to report any signs of infection
l INTERACTIONS → Appendix 1: ranibizumab
▶ Frequency not known Arterial thromboembolism
l CONCEPTION AND CONTRACEPTION Manufacturer
recommends women use effective contraception during
and for at least 3 months after treatment.
l PREGNANCY Manufacturer advises avoid unless potential
l BREAST FEEDING Manufacturer advises avoid—no
▶ Manufacturer advises monitor intra-ocular pressure,
perfusion of the optic nerve head, and for signs of ocular
infection following injection.
▶ Manufacturer advises monitor visual acuity.
l DIRECTIONS FOR ADMINISTRATION For further information
on administration, consult product literature.
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Ranibizumab for treating choroidal neovascularisation
associated with pathological myopia (November 2013)
Ranibizumab is recommended as an option for treating
visual impairment due to choroidal neovascularisation
secondary to pathological myopia when the manufacturer
provides ranibizumab with the discount agreed in the
www.nice.org.uk/guidance/ta298
▶ Ranibizumab for the treating visual impairment caused by
macular oedema secondary to retinal vein occlusion (May
Ranibizumab is recommended as an option for treating
visual impairment caused by macular oedema:
. following central retinal vein occlusion or
. following branch retinal vein occlusion only if treatment
with laser photocoagulation has not been beneficial, or
when laser photocoagulation is not suitable because of
the extent of macular haemorrhage and
. only if the manufacturer provides ranibizumab with the
discount agreed in the patient access scheme revised in
the context of NICE technology appraisal guidance 274.
Patients currently receiving ranibizumab whose disease
does not meet the criteria listed above should be able to
continue treatment until they and their clinician consider
www.nice.org.uk/guidance/ta283
▶ Ranibizumab for treating diabetic macular oedema (February
Ranibizumab is recommended as an option for the
treatment of visual impairment due to diabetic macular
. the eye has a central retinal thickness of
400 micrometres or more at the start of treatment and
. the manufacturer provides ranibizumab with the
discount agreed in the patient access scheme (as revised
Patients currently receiving ranibizumab for treating
visual impairment due to diabetic macular oedema whose
disease does not meet the criteria should be able to
continue treatment until they and their clinician consider
www.nice.org.uk/guidance/ta274
▶ Ranibizumab and pegaptanib for the treatment of age-related
macular degeneration (updated May 2012) NICE TA155
Ranibizumab is recommended for the treatment of wet
age-related macular degeneration if all of the following
. the best corrected visual acuity is between 6/12 and
. there is no permanent structural damage to the central
. the lesion size is less than or equal to 12 disc areas in
. there is evidence of recent presumed disease
. the manufacturer provides ranibizumab with the
discount agreed in the patient access scheme (as revised
Ranibizumab should only be continued in patients who
maintain adequate response to therapy.
www.nice.org.uk/guidance/ta155
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (June 2007)
that ranibizumab (Lucentis ®) is accepted for use within
NHS Scotland for the treatment of neovascular (wet) agerelated macular degeneration.
The Scottish Medicines Consortium has advised
(December 2012) that ranibizumab (Lucentis ®) is accepted
for restricted use within NHS Scotland for the treatment of
visual impairment due to diabetic macular oedema in
adults with best corrected visual acuity 75 Early Treatment
Diabetic Retinopathy Study letters or less at baseline. This
advice is contingent upon the continuing availability of
the patient access scheme in NHS Scotland or a list price
The Scottish Medicines Consortium has advised (May
2013) that ranibizumab (Lucentis ®) is accepted for use
within NHS Scotland for the treatment of macular oedema
secondary to branch or central retinal vein occlusion in
adults. This advice is contingent upon the continuing
availability of the patient access scheme in NHS Scotland
or a list price that is equivalent or lower.
The Scottish Medicines Consortium has advised
(November 2013) that ranibizumab (Lucentis ®) is accepted
for use within NHS Scotland for the treatment of visual
impairment due to choroidal neovascularisation secondary
to pathologic myopia in adults. This advice is contingent
upon the continuing availability of the patient access
scheme in NHS Scotland or a list price that is equivalent or
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised (June
2018) that ranibizumab (Lucentis ®) is recommended as an
option for use within NHS Wales for the treatment of
visual impairment in adults due to choroidal
neovascularisation not due to pathological myopia or wet
age-related macular degeneration. This recommendation
applies only in circumstances where the approved Patient
Access Scheme (PAS) is utilised or where the list/contract
price is equivalent or lower than the PAS price.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Lucentis (Novartis Pharmaceuticals UK Ltd)
Ranibizumab 10 mg per 1 ml Lucentis 2.3mg/0.23ml solution for
injection vials | 1 vial P £551.00 (Hospital only)
l DRUG ACTION Following intravenous infusion, verteporfin
is activated by local irradiation using non-thermal red
light to produce cytotoxic derivatives.
Photodynamic treatment of age-related macular
degeneration associated with predominantly classic
subfoveal choroidal neovascularisation or with
pathological myopia (specialist use only)
, dose to be given over 10 minutes
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l CAUTIONS Avoid extravasation . biliary obstruction . photosensitivity
l INTERACTIONS → Appendix 1: verteporfin
▶ Rare or very rare Malaise .retinal ischaemia
▶ Frequency not known Myocardial infarction .retinal
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk (teratogenic in animal studies).
l BREAST FEEDING No information available—manufacturer
advises avoid breast-feeding for 48 hours after
l HEPATIC IMPAIRMENT Manufacturer advises caution in
moderate impairment and avoid in severe impairment (no
l DIRECTIONS FOR ADMINISTRATION For information on
administration and light activation, consult product
For intravenous infusion (Visudyne ®), give intermittently
in Glucose 5%; reconstitute each 15 mg with 7 ml water for
injections to produce a 2 mg/ml solution then dilute
requisite dose with infusion fluid to a final volume of
30 mL and give over 10 minutes; protect infusion from
light and administer within 4 hours of reconstitution.
Incompatible with sodium chloride infusion.
l PATIENT AND CARER ADVICE Photosensitivity—avoid
exposure of unprotected skin and eyes to bright light
during infusion and for 48 hours afterwards.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
EXCIPIENTS: May contain Butylated hydroxytoluene
▶ Visudyne (Novartis Pharmaceuticals UK Ltd)
Verteporfin 15 mg Visudyne 15mg powder for solution for infusion
vials | 1 vial P £850.00 (Hospital only)
Fluocinolone acetonide 08-Feb-2019
Treatment of visual impairment associated with chronic
diabetic macular oedema which is insufficiently
responsive to available therapies (specialist use only)
▶ Adult: 190 micrograms, to be administered into the
l CAUTIONS Raised baseline intra-ocular pressure
l INTERACTIONS → Appendix 1: fluocinolone
▶ Common or very common Cataract. eye discomfort. glaucoma . haemorrhage . vision blurred
▶ Uncommon Eye disorders . headache
▶ Frequency not known Thromboembolism
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—no information available.
l BREAST FEEDING Manufacturer advises avoid unless
▶ Monitor for raised intra-ocular pressure (particularly if
raised at baseline), retinal detachment, endophthalmitis,
vitreous haemorrhage or detachment within 2–7 days
▶ Monitor intra-ocular pressure at least every 3 months
thereafter (for approximately 36 months).
l DIRECTIONS FOR ADMINISTRATION Concurrent
administration to both eyes not recommended. For further
information on administration and repeat dosing, consult
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Fluocinolone acetonide intravitreal implant for treating
chronic diabetic macular oedema after an inadequate
response to prior therapy (November 2013) NICE TA301
Fluocinolone acetonide intravitreal implant (Iluvien ®) is
recommended as an option for treating chronic diabetic
macular oedema that is insufficiently responsive to
. the implant is to be used in an eye with an intra-ocular
. the manufacturer provides fluocinolone acetonide
intravitreal implant with the discount agreed in the
www.nice.org.uk/guidance/ta301
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (February
2014) that fluocinolone acetonide intravitreal implant
(Iluvien ®) is recommended for restricted use within NHS
Scotland for the treatment of vision impairment associated
with chronic diabetic macular oedema, considered
insufficiently responsive to available therapies, only in
patients in whom the affected eye is pseudophakic (has an
artificial lens after cataract surgery), and retreatment
would take place only if the patient had previously
responded to treatment with fluocinolone acetonide and
subsequently best corrected visual acuity had deteriorated
to less than 20/32. This advice is contingent upon the
continuing availability of the patient access scheme in
NHS Scotland or a list price that is equivalent or lower.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Iluvien (Alimera Sciences Ltd)
Fluocinolone acetonide 190 microgram ILUVIEN 190microgram
intravitreal implant in applicator | 1 device P £5,500.00
DRUGS FOR METABOLIC DISORDERS ›
l DRUG ACTION Idebenone is a nootropic and antioxidant
that is thought to act by restoring cellular ATP generation,
thereby reactivating retinal ganglion cells.
Leber’s Hereditary Optic Neuropathy (initiated by a
▶ Common or very common Cough . diarrhoea . increased risk
SIDE-EFFECTS, FURTHER INFORMATION The metabolites of
idebenone may cause red-brown discolouration of the
urine. This effect is harmless, but the manufacturer
advises caution as this may mask colour changes due to
other causes (e.g. renal or blood disorders).
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—no information available.
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution (no
l RENAL IMPAIRMENT Manufacturer advises use with
caution—no information available.
l NATIONAL FUNDING/ACCESS DECISIONS
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (May 2017)
that idebenone (Raxone ®) is accepted for restricted use
within NHS Scotland for the treatment of visual
impairment in patients with Leber’s Hereditary Optic
Neuropathy (LHON) who are not yet blind i.e. they do not
meet the UK criteria to be registered as severely sight
impaired. This advice is contingent upon the continuing
availability of the Patient Access Scheme in NHS Scotland
or a list price that is equivalent or lower.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: tablet
CAUTIONARY AND ADVISORY LABELS 14, 21
▶ Raxone (Santhera (UK) Ltd) A
Idebenone 150 mg Raxone 150mg tablets | 180 tablet P £6,364.00
RECOMBINANT PROTEOLYTIC ENZYMES
Treatment of vitreomacular traction, including when
associated with a macular hole of diameter less than or
equal to 400 microns (specialist use only)
▶ Adult: 125 micrograms for 1 dose, to be administered
into the affected eye, concurrent administration to
l CONTRA-INDICATIONS Active or suspected ocular or
periocular infection . aphakia . exudative age-related
macular degeneration . high myopia . history of
rhegmatogenous retinal detachment. ischaemic
retinopathies . large diameter macular hole
(> 400 microns). lens zonule instability . proliferative
diabetic retinopathy .recent intra-ocular injection
(including laser therapy).recent ocular surgery .retinal
vein occlusions . vitreous haemorrhage
l CAUTIONS History of uveitis (including severe active
inflammation). non-proliferative diabetic retinopathy . significant eye trauma
▶ Common or very common Dry eye . eye discomfort. eye
disorders . eye inflammation . haemorrhage .retinal
pigment epitheliopathy . vision disorders
l PREGNANCY Manufacturer advises use only if potential
benefit outweighs risk—no information available.
l BREAST FEEDING Manufacturer advises use only if
potential benefit outweighs risk—no information
l MONITORING REQUIREMENTS Monitor intra-ocular
pressure, visual acuity, and for signs of intra-ocular
inflammation or infection following injection.
l DIRECTIONS FOR ADMINISTRATION For further information
on administration, consult product literature.
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Ocriplasmin for treating vitreomacular traction (October
Ocriplasmin is recommended as an option for treating
vitreomacular traction in adults, only if:
. an epiretinal membrane is not present and
. they have a stage II full-thickness macular hole with a
diameter of 400 microns or less and/or
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised (July 2014)
that ocriplasmin (Jetrea ®) is accepted for restricted use
within NHS Scotland for the treatment of patients with
vitreomacular traction plus macular hole, regardless of
whether they have epiretinal membrane formation, and in
patients with vitreomacular traction alone (no epiretinal
membrane and no macular hole).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Ocriplasmin 1.25 mg per 1 ml Jetrea 0.375mg/0.3ml solution for
injection vials | 1 vial P £2,500.00 (Hospital only)
BNF 78 Vitreomacular traction 1193
3 Nasal inflammation, nasal polyps and rhinitis 1204
3 Oral ulceration and inflammation 1214
4 Oropharyngeal bacterial infections 1217
5 Oropharyngeal fungal infections 1218
6 Oropharyngeal viral infections 1219
Otitis externa is an inflammatory reaction of the meatal skin.
It is important to exclude an underlying chronic otitis media
before treatment is commenced. Many cases recover after
thorough cleansing of the external ear canal by suction or
dry mopping. A frequent problem in resistant cases is the
difficulty in applying lotions and ointments satisfactorily to
the relatively inaccessible affected skin. The most effective
method is to introduce a ribbon gauze dressing or sponge
wick soaked with corticosteroid ear drops or with an
astringent such as aluminium acetate solution p. 1199. When
this is not practical, the ear should be gently cleansed with a
probe covered in cotton wool and the patient encouraged to
lie with the affected ear uppermost for ten minutes after the
canal has been filled with a liberal quantity of the
If infection is present, a topical anti-infective which is not
used systemically (such as neomycin sulfate p. 1196 or
clioquinol) may be used, but for only about a week as
excessive use may result in fungal infections; these may be
difficult to treat and require expert advice. Sensitivity to the
anti-infective or solvent may occur and resistance to
antibacterials is a possibility with prolonged use. Aluminium
acetate ear drops are also effective against bacterial infection
and inflammation of the ear. Chloramphenicol p. 1196 may
be used but the ear drops contain propylene glycol and cause
hypersensitivity reactions in about 10% of patients.
Solutions containing an anti-infective and a corticosteroid
are used for treating cases where infection is present with
polymyxins in patients with a perforated tympanic
membrane (eardrum) or patent grommet. However, some
specialists do use these drops cautiously in the presence of a
perforation or patent grommet in patients with chronic
suppurative otitis media and when other measures have
failed for otitis externa; treatment should be considered only
by specialists in the following circumstances:
. drops should only be used in the presence of obvious
. treatment should be for no longer than 2 weeks;
. patients should be counselled on the risk of ototoxicity
and given justification for the use of these topical
. baseline audiometry should be performed, if possible,
before treatment is commenced.
Clinical expertise and judgement should be used to assess
the risk of treatment versus the benefit to the patient in such
A solution of acetic acid 2% acts as an antifungal and
antibacterial in the external ear canal. It may be used to treat
mild otitis externa but in severe cases an antiinflammatory
preparation with or without an anti-infective drug is
required. A proprietary preparation containing acetic acid
2% (EarCalm® spray) is on sale to the public.
For severe pain associated with otitis externa, a simple
analgesic, such as paracetamol p. 444 or ibuprofen p. 1141,
can be used. A systemic antibacterial can be used if there is
spreading cellulitis or if the patient is systemically unwell.
When a resistant staphylococcal infection (a boil) is present
in the external auditory meatus, flucloxacillin p. 554 is the
drug of choice; ciprofloxacin p. 1196 (or an aminoglycoside)
may be needed in pseudomonal infections which may occur
if the patient has diabetes or is immunocompromised.
The skin of the pinna adjacent to the ear canal is often
affected by eczema. A topical corticosteroid cream or
ointment is then required, but prolonged use should be
Acute otitis media is a self-limiting condition that mainly
affects children. It is characterised by inflammation in the
middle ear associated with effusion and accompanied by the
rapid onset of signs and symptoms of an ear infection. The
infection can be caused by viruses or bacteria; often both are
Children with acute otitis media usually present with
symptoms such as ear pain, rubbing of the ear, fever,
irritability, crying, poor feeding, restlessness at night, cough,
or rhinorrhoea. Symptoms usually resolve within 3 to 7 days
without antibacterial drugs. The use of antibacterials
generally does not prevent common complications of acute
otitis media such as short-term hearing loss, perforated
eardrum, or recurrent infection. Acute complications such as
mastoiditis, meningitis, intracranial abscess, sinus
thrombosis, and facial nerve paralysis, are rare.
g Children and their carers should be given advice
about the usual duration of acute otitis media, self-care of
1194 Ear, nose and oropharynx BNF 78
symptoms such as pain and fever with paracetamol or
ibuprofen p. 1141, and when to seek medical help. In
children aged 3 years and over who do not have a perforated
eardrum, pain can be relieved with anaesthetic ear drops in
addition to oral analgesics [unlicensed use]. Children and
their carers should be reassured that antibacterial drugs are
An immediate antibacterial drug should be given if the
child is systemically very unwell, has signs or symptoms of a
more serious illness, or is at high risk of complications such
as significant heart, lung, renal, liver or neuromuscular
disease, immunosuppression, cystic fibrosis, or young
children who were born prematurely. An immediate
antibacterial drug can also be considered if otorrhoea is
present, or in children under 2 years of age with bilateral
otitis media. See Antibacterial therapy for otitis media in Ear
infections, antibacterial therapy p. 511.
Children with acute otitis media associated with a severe
systemic infection or acute complications should be referred
Otitis media with effusion (glue ear) occurs in about 10% of
children and in 90% of children with cleft palates. Systemic
antibacterials are not usually required. If glue ear persists for
more than a month or two, the child should be referred for
assessment and follow up because of the risk of long-term
hearing impairment which can delay language development.
Untreated or resistant glue ear may be responsible for some
types of chronic otitis media.
Opportunistic organisms are often present in the debris,
keratin, and necrotic bone of the middle ear and mastoid in
patients with chronic otitis media. The mainstay of
treatment is thorough cleansing with aural microsuction
which may completely resolve long-standing infection. Local
cleansing of the meatal and middle ear may be followed by
treatment with a sponge wick or ribbon gauze dressing
soaked with corticosteroid ear drops or with an astringent
such as aluminium acetate solution p. 1199; this is
particularly beneficial for discharging ears or infections of
the mastoid cavity. An antibacterial ear ointment may also
be used. Acute exacerbations of chronic infection may also
require systemic treatment with amoxicillin p. 548 (or
erythromycin p. 539 if penicillin-allergic); treatment is
adjusted according to the results of sensitivity testing.
In view of reports of ototoxicity, manufacturers
contraindicate topical treatment with ototoxic antibacterials
in the presence of a tympanic perforation or patent
grommet. Ciprofloxacin p. 1196 or ofloxacin eye drops
p. 1173 used in the ear [unlicensed use] or ear drops [both
unlicensed; available from ‘special-order’ manufacturers or
specialist importing companies] are an effective alternative
to such ototoxic ear drops for chronic otitis media in patients
with perforation of the tympanic membrane.
However, some specialists do use ear drops containing
aminoglycosides or polymyxins [unlicensed indications]
cautiously in patients with chronic suppurative otitis media
and a perforation of the tympanic membrane, if the otitis
media has failed to settle with systemic antibacterials;
treatment should be considered only by specialists in the
. drops should only be used in the presence of obvious
. treatment should be for no longer than 2 weeks;
. patients should be counselled on the risk of ototoxicity
and given justification for the use of these topical
. baseline audiometry should be performed, if possible,
before treatment is commenced.
Clinical expertise and judgement should be used to assess
the risk of treatment versus the benefit to the patient in such
circumstances. It is considered that the pus in the middle ear
associated with otitis media also carries a risk of ototoxicity.
Ear wax (cerumen) is a normal bodily secretion which
provides a protective film on the meatal skin and need only
be removed if it causes hearing loss or interferes with a
Ear wax can be softened using simple remedies such as
olive oil ear drops or almond oil ear drops; sodium
bicarbonate ear drops p. 1200 are also effective, but may
cause dryness of the ear canal. If the wax is hard and
impacted, the drops can be used twice daily for several days
and this may reduce the need for mechanical removal of the
wax. The patient should lie with the affected ear uppermost
for 5 to 10 minutes after a generous amount of the softening
remedy has been introduced into the ear. Some proprietary
preparations containing organic solvents can irritate the
meatal skin, and in most cases the simple remedies indicated
above are just as effective and less likely to cause irritation.
Docusate sodium p. 1200 or urea hydrogen peroxide p. 1200
are ingredients in a number of proprietary preparations for
If necessary, wax may be removed by irrigation with water
(warmed to body temperature). Ear irrigation is generally
last six weeks, in otitis externa, in patients with cleft palate,
a history of ear drum perforation, or previous ear surgery. A
person who has hearing in one ear only should not have that
ear irrigated because even a very slight risk of damage is
unacceptable in this situation.
ANTIBACTERIALS › AMINOGLYCOSIDES
Bacterial infection in otitis externa
▶ Adult: (consult product literature)
l CONTRA-INDICATIONS Perforated tympanic membrane
l CAUTIONS Avoid prolonged use
l MEDICINAL FORMS No licensed medicines listed.
Combinations available: Dexamethasone with framycetin
sulfate and gramicidin, p. 1164
Bacterial infection in otitis externa
▶ Child: Apply 2–3 drops 4–5 times a day, (including a
▶ Adult: Apply 2–3 drops 4–5 times a day, (including a
l CONTRA-INDICATIONS Patent grommet (although may be
used by specialists, see Ear p. 1194). perforated tympanic
membrane (although may be used by specialists, see Ear
l CAUTIONS Avoid prolonged use
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